Business Process Specialist

1 week ago

Houston, United States Integrated Resources Full time
Job Title: Business Process Specialist
Location: Bellaire, TX
Duration: 3 Months Contract

Job Summary:
Support and develop programs aligned with Health Plan strategic goals through effective and timely assessment and equitable distribution of resources and assignments, education and implementation of processes and procedures that provide and maintain a cost effective provider network for Health Plan.

Responsibility:
  • Research, develop, and implement a coordinated approach to ensure regulatory adherence for the department.
  • Through participation in Medical Policy, Reimbursement Committee, and other workgroups as needed, provides support for the facilitation of process and/or system changes.
  • Proposes, implements, and supports quality control measures related to practice and/or system changes that impact claims adjudication.
  • Performs review of current and newly implemented processes to ensure accurate reports and/or other deliverables.
  • Leads collaborations with other departments to ensure compliance standards are met.
  • Process and workflow management for audit response, contract adherence, and regulatory compliance functions.
  • Prioritizes key project tasks and deliverables and identifies project risks, issues and dependencies.

Key Skills Require:
  • They have to have demonstrated experience creating a reimbursement policy / operating guideline from regulation
  • They have to have proficiency in excel (data extraction, pivot, VLOOKUP, sum, import / export data into / out of excel)
  • They have to demonstrate knowledge of Medicaid, regulatory sites referenced, and examples of how use and reference
  • They have to be able to give code level examples of code analysis and remediation

Skills:
  • Must demonstrate ability to achieve effective issue resolution.
  • Must have excellent written and verbal communication skills, and the ability to interact with a wide variety of individuals and handle several complex situations simultaneously.
  • Must have leadership, creativity, integrity and initiative, and sound problem solving skills.
  • Must provide attention to detail and follow up.

Reimbursement Analyst Summary:
  • Leads in the development, planning, and implementation of new or current medical coding reimbursement policies leveraging medical coding certification and billing reconciliation experience. Conducts financial impact analysis based on claim utilization based on changes to reimbursement policy, MCO notices, Bulletins, and HHSC / TMPPM guidelines. Recommends optimal system configuration based on medical coding billing / reimbursement experience. Leads medical policy meetings and participates in policy discussion by providing comments and recommendations orally or in writing.

Knowledge, Skills, and Abilities:
  • Knowledge of health and human services agencies and programs, and state and federal Medicaid and CHIP laws and regulations.
  • Strong skills in analyzing and evaluating complex federal and state legislation and demonstrating through financial impact analysis.
  • Skilled in researching & analyzing medical policy and its impact to claims processing / adjudication and providing system optimization recommendation
  • Highly organized with the ability to manage several projects concurrently in a fast-paced environment and juggle competing priorities.
  • Strong skill in developing and evaluating policies and procedures, assessing risks, and making recommendations.
  • Strong written and oral communication skills, including the ability to make public presentations, and write technical information in an understandable format.
  • Skilled in project planning, evaluation, and implementation.
  • bility to effectively facilitate meetings and maintain working relationships with staff or program stakeholders.
  • bility to exercise creative problem-solving techniques in a highly complex environment.
  • bility to work cooperatively as a team member in a fast-paced, deadline-orientated environment.
  • bility to work independently and perform work with a high degree of attention to detail.
  • Proficient in the use of Microsoft Office products.
  • Performs and plans configuration changes for coding, contracts, benefits, fee schedules and claim editing rules as needed

Education:
  • Required- Bachelor's Degree- Business, Health Care Administration, Public Health, Nursing, MIS or an IS related field.
  • Required- 2 years' Experience in a managed care organization (MCO) or related healthcare organization.
  • Master's degree in Business, Health Care Administration, Public Health, Nursing, MIS or an IS-related field may substitute for 2 years of required experience.

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